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ANNE LITTLE, MPH, AE-C
DIRECTOR
CLAUDIA GUGLIELMO, MPA, AE-C
DIRECTOR
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WHAT IS ASTHMA?
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4
ASTHMA IS
• Inflammation (swelling) of the lining of the airways
• Bronchoconstriction (tightening of the bands of
smooth muscles surrounding the airways) which
reduces the width of the airways
• Excess mucus production that further narrows the
airways
A chronic inflammatory disorder of the airways
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Symptoms
Airway
inflammation
Airflow obstruction
Bronchial hyperresponsiveness
A LOT GOING ON BENEATH THE SURFACE
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WHAT DOES ASTHMA LOOK LIKE?
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MYTHS & TRUTHS ABOUT ASTHMA
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MYTHS & TRUTHS ABOUT ASTHMA
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MYTHS & TRUTHS ABOUT ASTHMA
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ASTHMA STATISTICS
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Asthma Facts in the US
Asthma’s Impact on the NationData from the CDC National Asthma Control Program
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1,400,000 adults
400,000 children
Who has
asthma
in NYS?
The average cost of an asthma hospitalization:
$18,625
Total projected cost for asthma in 2014 was
$3.45 billion, including loss of productivity
Asthma is the most common chronic condition among children and a leading cause of school absences.
Kids with asthma
who are exposed
to secondhand
smoke at home
are 2X more likely
to be hospitalized
for an asthma
attack.
POOR ASTHMA CONTROL
LEADS TO:
38,000
Hospitalizations
165,000+
Emergency
Department Visits
AND 255 DEATHSNYS Annually
ASTHMA IS COSTLY
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RISK FACTORS FOR DEATH FROM ASTHMA
• History of severe exacerbations
• Prior intubation for asthma
• Prior admission to Intensive Care Unit
• 2 or more hospital admissions in the past year
• 3 or more emergency room visits in the past year
• Hospital or emergency room visit past month
• Use of >2 canisters per month of inhaled short-acting beta2 –
agonist
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RISK FACTORS FOR DEATH FROM ASTHMA
• Chronic use of systemic corticosteroids
• Poor perception of airflow obstruction or its severity
• Co-morbid conditions (other diseases)
• Serious psychiatric disease or psychosocial problems
• Low socioeconomic status and urban residence
• Illicit drug use
• Sensitivity to alternaria-mold
• Lack of written asthma action plan
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Early warning signs suggest the possibility of an asthma attack and are not the
same for everyone.
✓ Shortness of breath
✓ Tightness in chest
✓ Pain in chest
✓ Less able to exercise
✓ Tired
✓ Itchy throat
✓ Watery eyes
✓ Dark circles around eyes
✓ Congestion
✓ Feeling Sad
BEFORE SYMPTOMS OCCUR: EARLY WARNING SIGNS
✓ Fever
✓ Clammy skin
✓ Pale
✓ Dry Mouth
✓ Fast Heartbeat
✓ Dark Circles
✓ Sneezing
✓ Gets easily excited or upset
✓ Feels Restless
Early treatment is always most helpful, waiting for an episode to become
full-blown usually means it will take more time and treatment to get relief.
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SYMPTOMS OF ASTHMA
Wheeze
CoughTight Chest
Difficulty breathing
shortness of breath
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20
National Asthma Education And
Prevention Program Expert Panel
Report 3: Guidelines For The
Diagnosis And Management Of
Asthma
www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm
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FOUR COMPONENTS OF ASTHMA MANAGEMENT
Measures of assessment
and monitoring
Education for a partnership in asthma care
Control of environmental conditions and
comorbid conditions
Pharmacologic therapy
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SIX PRIORITY MESSAGES
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ASSESSING ASTHMA SEVERITY
National Asthma Education and Prevention Program. Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma (EPR-3 2007). U.S.
Department of Health and Human Services. Available at: http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.pdf. Accessed August 29, 2007.
IMPAIRMENT
Current
frequency and
intensity of
symptoms and
functional
limitations
RISK
Future
likelihood of
asthma
exacerbations
and progressive
decline in lung
function over
time
SEVERITY
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STEPWISE TREATMENT OF ASTHMA
• Based on severity assessment the HCP
will choose the appropriate
medication
• For all patients with persistent asthma
(mild-moderate-severe) the preferred
first line treatment is to use a daily
inhaled steroid
• Health Home Care Managers should
ask what type of medication the
member is taking and how often
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ASTHMA MEDICATIONS
• Controllers (anti-inflammatory)
• Help to prevent an asthma episode
• Are taken daily
• Does not eliminate the need for quick relief medications
• Quick relief medications (inhaled bronchodilators)
• Fast-acting (RESCUE)
• Relieve symptoms during an asthma episode
• Are taken as needed
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VALVED HOLDING CHAMBERS OR SPACERS
• The most effective way to deliver asthma medications when using an inhaled medication
• Slows down the speed of delivery such that there is medication deposition to the airways, rather than the posterior wall of the pharynx
• Decreases need for coordination between actuation and inhalation
• Mouth piece or face mask available: Must be a one way valved holding chamber
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ASTHMA ACTION PLANS
• Every child with asthma should have an action plan, especially those on more than one medication
• A copy should be kept with the medical provider, and provided to school/camp, coach, babysitter/care provider
• Empowers caregivers to administer rescue medications
• An asthma action plan should be created with the provider with input from the patient and the family
• Health Home Care Managers can be the bridge between the family and the provider to help develop an asthma action that works for them
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ASTHMA ACTION PLANS
An action plan should contain:
• The frequency and dose of daily medications written in simple language
• The medications to add when a person starts having symptoms, including dose & frequency
• Signs and symptoms to monitor for
• An emergency contact number for the doctor
• Indications for when to go to the ER
• Permission for all medication use at school
• Permission for independent medication carry and use at school
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ACTIONS TO TAKE FOR AN ASTHMA ATTACK
• Have someone stay with the person
• Follow the person’s Asthma Action Plan
• Make certain quick relief medicine is available and used properly
• Observe person to ensure they improve
• Communicate with emergency contacts if the person with asthma is
experiencing breathing difficulties
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ACTIONS TO TAKE FOR AN ASTHMA EMERGENCY
• Have someone stay with the person
• If person does NOT have quick-relief medicine or the medication DOES NOT WORK – CHECK ASTHMA ACTION PLAN
OR
• Call 911 if:
• Person cannot breathe
• Struggling to breathe
• Chest/neck are pulled in or sucked in with each breath
• Trouble walking or talking
• Nostrils wide open
• Lips or fingertips are blue
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SCHEDULE FOLLOW-UP VISITS
• Schedule follow-up visits at periodic intervals to assess asthma
control and modify treatment if needed
✓ 1-6 months depending on control
✓ 3-month intervals if step down in medication is anticipated
• Consider a patient reminder system for these visits
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GOALS OF ASTHMA CONTROL
✓ Sleep through the night
✓ Not cough or wheeze during the
day or night
✓ Be physically active
✓ Not miss school or work due to
asthma
✓ Not have asthma-related visits to
the emergency room
✓ Not have a hospitalization due to
asthma
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GOOD CONTROL DEPENDS ON
• Being able to get medical care
• Having good self-management
skills
• Having good communication
between a person with asthma
and those around them
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HOW DO YOU KNOW YOUR ASTHMA IS NOT IN CONTROL?
• Do you take your rescue inhaler more than TWO times per week?
• Do you awaken at night with asthma more than TWO times per month?
• Do you refill your rescue inhaler more than TWO times per year?
The Rules of Two
If you answer “YES” to any of these questions, speak to your HCP to discuss why
your asthma may not be in good control.
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AVAILABLE AT WWW.ASTHMA.COM
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CONTROL ENVIRONMENTAL EXPOSURES
• Review the environmental history of
exposures
• Develop a multi-pronged strategy to
reduce exposure to the patient’s triggers
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COMMON HOME TRIGGERS
Animal allergens
Dust mites
Cockroach allergens
Mold
Tobacco Smoke
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ANIMAL ALLERGENS
All warm-blooded animals produce flakes of skin (dander), feces, urine
and dried saliva that can cause allergic reactions.
• Best option - Keep animals out of house
• If you can’t keep the pet outside, keep it out of the bedroom
and keep the door shut
• Wash hands and clothes after contact with the pet
• Remove upholstered furniture and carpets from the home
or isolate the pet in areas without these items
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DUST MITES
• Require humidity and human dander to survive, thrive in most areas of
the US but usually not present in high altitudes or arid areas
• High levels are found in bedding, pillows, mattress, upholstered
furniture, carpets, clothes and soft toys
IMPORTANT: Since the patient’s bed is the most
likely place for dust mites to be found this is the
best place for trigger control measures
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DUST MITES CONTROL MEASURES
• Encase the pillow and mattress in an allergen-impermeable cover
• Wash all bedding in hot (>130ºF) water weekly*
• Keep humidity below 60% (ideally 30%-50%).
• Remove carpets from the bedroom
• Avoid sleeping or lying on upholstered furniture
• In children’s beds, minimize the number of stuffed toys; each week,
wash the toys in hot water or freeze them
• Room air filtration devices are not recommended to control dust mite
exposure – the allergens are air-borne only briefly and not removed via
air filtration.
(*Exposure to dry heat or freezing kills dust mites but does not remove the allergen.)
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COCKROACH CONTROL MEASURES
• Keep counters, sinks, tables and floors clean and clear of clutter.
• Fix plumbing leaks and other moisture problems.
• Remove piles of boxes, newspapers and other items where cockroaches
may hide.
• Seal all entry points.
• Make sure trash in your home is properly stored in containers with lids
that close securely; remove trash daily.
• Try using poison baits, boric acid or traps first before using pesticide
sprays.
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49
Common Home Triggers: Irritants
Molds
Basements
Bathrooms
Smoke &
Gases
Kerosene
heaters
Wood stoves
and/or
Fireplaces
(Nitrogen
Dioxide)
VOCs and
Strong
Smells
Hairspray,
cooking spray &
odors
Furniture polish
New carpets
Perfumes
Tobacco
Smoke
Secondhand
smoke
Thirdhand smoke
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MOLD CONTROL MEASURES
• Moisture control = mold control, so - ACT QUICKLY.
– If wet or damp materials or areas are dried 24-48 hours after a leak or spill, in most cases mold will not grow.
• Scrub mold off hard surfaces with detergent and water; dry completely.
• Absorbent or porous materials, such as moldy ceiling tiles and carpet, may have to be thrown away.
• Dehumidify basements if possible.
(SOURCE: A Brief Guide to Mold and Moisture in Your Home, EPA Publication
#402-K-02-003.)
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TOBACCO SMOKE CONTROL MEASURES
• If you smoke, ask for ways to help you quit. Ask family members
to quit.
• Do not allow smoking in your home or car.
• Be sure no one smokes at your child’s daycare or school.
• Advocate for smoke free workplaces.
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SECONDHAND AND THIRDHAND SMOKE
• Exposure is linked to increased asthma symptoms, decreased lung
function and greater use of health services among those who have
asthma.
• Message to smokers – Quit or at least smoke outside (may not
adequately reduce exposure).
• Provide smoking cessation support if possible.
• Thirdhand smoke clings to clothes, furniture, drapes, walls
bedding, carpets, vehicles and other surfaces long
after smoking has stopped
– Thirdhand smoke residue builds up over time
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TECHNIQUES THAT MAY MODIFY INDOOR AIR
• Vacuum 1-2 times per week
– Get someone else to do this if possible or wear a dust mask
• Damp mop
• Air conditioning during warm weather recommended for asthma
patients
• Dehumidifiers to reduce house-dust mite levels in high-humidity
areas
• HEPA filters to reduce airborne cat dander, mold spores and
particulate tobacco smoke.
– Not a substitute for more effective measures!
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HEALTH HOME CARE MANAGERS … FIRST LINE OF DEFENSE
• Work with children to find out when and
where in the home they have more
asthma symptoms
• Work with family members to examine
household conditions
• Work to assist and link the family to
available resources to make household
modifications
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OUTDOOR ENVIRONMENT
• Ask the patient:
“Is your asthma worse
in spring, summer, fall
or parts of the growing
season?”
Pollen and
Molds
• Avoid areas of high
pollution; stay indoors
on ozone alert days
when possible.
• Do not use air cleaners
that create ozone.
Ozone
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INFECTIONS
Viral respiratory infections
Respiratory infections can exacerbate asthma
symptoms, particularly in children under age 10.
Bacterial infections
Infections such as Mycoplasma and Chlamydia
may contribute to asthma exacerbations.
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INFECTIONS
Respiratory infections are the #1 trigger for children with asthma
Keep hands away
from faceWash hands Use separate towels Get a flu shot
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OTHER TRIGGERS
Exercise may be a trigger for
asthma, but asthma should not
limit physical activity
Strong
Emotions
Exercise-
Induced
Asthma
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59
Schools: Potential Concerns
• Fragrances (Magic Markers, air fresheners, art supplies)
• Animals in classroom
• Cleaning supplies
• Classroom environment (old carpeting, furniture)
• Insecticides, herbicides, fungicides
• Chalk dust, foods
• Access to medications
• Access to a school nurse
• Poor indoor air quality
• Leaky roofs/wet carpeting = Molds
• New carpeting/chemicals = Toxic fumes
• Building repairs/renovations = Dust
• Idling school busses =
Diesel fumes
• Unventilated portable classrooms
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60
Asthma-Friendly School Checklist
• Tobacco free campus? Good indoor air quality?
• Policy on inhalers?
• Written asthma emergency plan for teachers & staff?
• Updated asthma action plans for students with asthma on file at school?
• School nurse?
• Education for school staff/teachers about asthma?
• Degree of participation asthma student has in PE, sports, recess, field trips?
Health Home Care Managers can collaborate with the school to ensure a proper school environment and plan for the child
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Asthma-Friendly School Resources
It is recommended that a clinician prepare a written asthma action plan for the school setting.
In addition to medications and emergency response, this plan should identify factors that make
students’ asthma worse so that the school may help avoid exposure.
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SUMMARY
• Asthma episodes can be prevented.
• When asthma symptoms go away, asthma is still there.
• Asthma is treatable. All episodes should receive immediate attention.
• A severe asthma episode IS an emergency!
• A person with mild asthma can suffer a fatal episode.
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WHAT CAN A CARE MANAGER DO TO SUPPORT ASTHMA CONTROL?
A Health Home Care Manager can reinforce these key messages:
• People with asthma should always have their quick relief medication
with them for relief of symptoms.
• Controller medications should be taken every day, even when feeling
well, for people who have persistent asthma.
• It is important to identify asthma triggers and know how to avoid them.
• Good communication is essential for effective asthma management.
• With proper management, everyone with asthma can live active and
healthy lives.
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RESOURCES
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AVAILABLE FREE THROUGH NYS DOH
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HERE’S HOW TO GET THEM…
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OTHER RESOURCES
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AMERICAN LUNG ASSOCIATION RESOURCES
FREE
• Questions about Lung Health?: 1-800-LUNGUSA
• Lungtropolis: video game for kids ages 5-10
• Asthma Basics: 50-minute online program
• Freedom from Smoking online
• Asthma Educator Institute (AEI)
• Open Airways For Schools
• Kickin’ Asthma
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QUESTIONS?